In 1999, the reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) model was described by Glasgow et al. [4, 8] in an effort to identify the breadth of influences that promote the success or failure of health promotion efforts. They argue that the multitude of efficacy studies conducted with subjects, settings, and/or interventions that are biased toward the success of the proposal are destined to fail when applied outside the controlled setting of the research. Glasgow et al. also stress that the intervention proposal should include a plan to address all five of the major dimensions of RE-AIM. The specificity of these dimensions has made the RE-AIM model an exceptional framework around which program analysis and evaluation can be built in health promotion and injury prevention.

The RE-AIM model includes parameters addressing the micro or individual ­aspects of program success: reach and efficacy/effectiveness, as well as ­parameters focused on the implementing organization or setting: adoption, implementation, and maintenance. Glasgow and his coauthors [8] define reach as the number/percentage of all appropriate individuals that participate in the ­intervention as well as a critique of their representativeness of the population as a whole (e.g., age, gender, ­socioeconomic status, literacy, severity of condition). They emphasize the importance of accurately identifying the true size of the applicable population to appropriately gauge the degree of reach . The efficacy or effectiveness criterion addresses the measureable impact on the chosen outcome measure as demonstrated by high-quality evidence. These two criteria as well as the others are ­considered multiplicative factors whose interaction can significantly impact expected outcomes. For example, a health promotion program aimed at reducing childhood obesity that demonstrated 80 % effectiveness at reducing body mass index (BMI) in a controlled/funded research effort but only reaches 15 % of 1000 potential beneficiaries in a community effort is only successful in 120 people. Similarly, a less effective (40 %) intervention that reaches 80 % of potential beneficiaries is ultimately successful in 320 people [8].

Adoption is the first organizational level criterion and is defined as the number/percentage of “settings” that elect to implement the chosen program [8]. This criterion also includes commentary on the representativeness of those that participate compared to those settings that elect not to participate. These comparisons should include comments regarding staffing, funding, and facilities in order to accurately identify barriers to broader implementation. Implementation refers to the degree to which the selected program is delivered to the intended audience in accordance with the defined protocol. Implementation can be enumerated as successful participant contacts, percentage of times content is delivered accurately, or number/percentage of staff across settings that elect to participate. Similar to other criteria, it is important to identify characteristics of those staff that are compliant and consistently deliver content or choose to participate. Are those that participated representative of all personnel? How do they compare to published results or standards?

The final criterion of the RE-AIM model is maintenance. Maintenance has applicability at both the individual and organizational (setting) levels. Organizationally, maintenance refers to the long-term incorporation of the intervention into the daily practice, culture, and corporate policies greater than 6 months beyond the original implementation period [4]. Individually, maintenance can be reported as long-term (> 6 months) incorporation of promoted behaviors by percentage attrition .

The breadth and depth of analysis encouraged by the RE-AIM model provides a strong foundation for addressing barriers to successful implementation of injury prevention and health promotion programs. Using this model to review the health promotion and injury prevention efforts implemented by the US military and those of partner nations helps to identify barriers to successful mitigation of their public health concerns (e.g., impaired mental health, obesity, musculoskeletal injury, poor sleep hygiene, suicide). The remainder of this chapter is dedicated to the application of the RE-AIM framework as an evaluation tool to review a variety of health promotion and injury prevention efforts in the military setting. We will identify individual and corporate barriers at the strategic, operational, and tactical levels and make recommendations regarding future program development and implementation that will improve observed outcomes .

Reach is the first step in the RE-AIM model and is defined as an individual measure of participation [8]. Reach is the absolute number or percentage of target audience and representativeness of individuals who know about the initiative and are willing to participate in a given initiative [8]. On the surface, reach in a military setting ­appears easy as unit leaders can mandate that service members participate in approved, sanctioned programs. However, programs that are mandated often ­undermine adoption and long-term behavior change required for the program ­maintenance. For example, fitness programs are often mandated for active duty service members to help maintain readiness, including maintenance of physical performance requirements and height/weight standards. Despite years of program compliance, upon discharge from the military the average service member gains weight at a higher rate than active duty service members. Specifically, around the time of discharge from the military, men and women gain 12.6 or 13.9 lbs on average, respectively [10]. Higher rates of being physically inactive, smoking, alcohol consumption, and diabetes have also been reported after discharge from the military, when programs are no longer mandated [11]. Additionally, in the military setting, reach is often limited due to a diminished understanding of what programs and resources are available in the local environment. This is complicated by the high operational tempo, limited time due to competing demands, and a lack of leadership support for some of the programs. Reach in a military setting is also complicated by the fact that service members typically change duty locations every 3–4 years. ­Efforts to ensure similar resources are available across installations and can assist with maximizing awareness and ultimately the reach of an injury prevention program. With that in mind, the success of reaching the target population depends upon a greater understanding of the characteristics of the target population, specifically the psychosocial and medical history. For example, a history of previous musculoskeletal injury is one of the single most significant risk factors for subsequent injury, but this information is rarely relayed to unit commanders when service members change duty stations, which can limit the reach of injury prevention efforts.

Effectiveness refers to the ability of the program to generate appropriate positive change in health and injury prevention, resulting in a positive impact on ­quality of life, performance, and military readiness . Abraham et al. [22] described the impact of a prevention program as a combination of the program’s reach and its­ ­effectiveness (I = R × E). Although evidence-based interventions that prevent injuries may have efficacy in a specific target population under controlled conditions, the ­effectiveness of delivering that program to a wider audience in real-world settings may not have the same results. While it is necessary for effective programs to have demonstrated efficacy, the program efficacy is not sufficient for programs to be effective in ­real-world settings. Specifically, effective injury prevention interventions should produce robust effects across multiple subpopulations and settings. Additionally, an effective program should have minimal to no adverse outcomes. Individuals developing injury prevention programs should account for the unanticipated negative effects that might be associated with labeling an individual at increased risk for injury and requiring additional or remedial training [23, 24].

Adoption refers to the proportion of individuals or organizations that adopt the ­injury prevention program and the determination of associated barriers to adoption by nonparticipating individuals and organizations [7, 8]. To address low adoption rates, leaders developing injury prevention, health promotion, and performance optimization programs should consider many barriers that could negatively influence ­adoption of a new and innovative program. Injury prevention , health promotion, or performance optimization programs should be designed so they can be easily adopted across a variety of military settings (e.g., Active Duty, Reserve, and National Guard). To maximize adoption, a program should be adaptable to meet the specific needs of the target audience (special operations, combat units, combat support units, and combat service support units). Additionally, the program has to be adaptable in a variety of climates: hot, cold, humid as well as at higher altitudes. Can the program be adopted by high-risk populations in the typical constrained resource setting? Do the units have organic assets (e.g., medical staff, master fitness trainers, master resiliency trainers) to ensure the program is adopted properly? Is the ­program aligned with other programs so that it can be easily adapted and is synergistic with other demands and priorities? To maximize adoption, the program development team has to plan for the program’s costs and the level of resources and expertise required [3]. Padua et al. describe the following steps to help improve adoption of injury ­prevention programs: (1) establish support for the program and have key stakeholders identify barriers to implementation and strategies to overcome those barriers, (2) develop programs that apply the best available evidence that incorporates strategies to overcome the ­identified barriers, (3) ensure competency and self-efficacy of the trainers that will lead the program, (4) provide routine feedback and coaching to the trainers to ensure program fidelity, and (5) reduce feedback (both quantity and frequency) to the trainers based on their ability to effectively implement the program [35].